<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 343626109
Report Date: 09/16/2024
Date Signed: 09/16/2024 11:29:44 AM

Document Has Been Signed on 09/16/2024 11:29 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MEHDIZADE, KHADIJAFACILITY NUMBER:
343626109
ADMINISTRATOR/
DIRECTOR:		MEHDIZADE, KHADIJAFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(916) 612-3183
CITY:SACRAMENTOSTATE: CAZIP CODE:
95864
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 1DATE:
09/16/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:25 AM
MET WITH:Khadija Mehdizade and Ali RezaiTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On Monday September 16th, 2024 Licensing Program Analyst (LPA) Mandie Goodwin met with Applicants Khadija Mehdizade and Ali Rezai for the purpose of an announced pre-licensing inspection. This is a change of location. Licensees were previously licensed under facility #343624523. LPA informed applicants that once licensed the previous license will close. A fire clearance approval was received on 9/3/24 for the new facility. During today’s inspection LPA observed one child that lives in the home and is under the age of 10. All individuals subject to criminal background review have cleared background checks. Applicant plans to operate Monday through Friday from 7:00 AM to 9:00 PM, or as needed.

A health and safety inspection was conducted inside and outside the home. The single story home consists of a living room, dining room, kitchen, 3 bedrooms, 2 bathrooms, a laundry room, a detached garage, and fully fenced backyard. The off limits areas include the laundry room and the bathroom next to laundry room, the 2nd bedroom on the left, and the garage. Applicant understands that children may never access these off limit areas. There are no stairs in the home.

Toxic and hazardous items are inaccessible to children and out of children’s reach. LPA advised the applicant that if there are ever any poisons at the home, all poisons must be locked with a key lock or combination lock. A functioning smoke detector and carbon monoxide detector was observed, and a fully charged fire extinguisher was observed. Applicant states there are no weapons in the home. There were no bodies of water.

Applicant has completed the required Preventative Health and Safety course with the Lead Poisoning Prevention training. LPA discussed the requirement to renew EMSA approved pediatric CPR/First Aid trainings every two years to remain in compliance. Applicant is exempt from mandated reporter training as it is not offered in her first language at this time. Continued on 809-C

SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Mandie Goodwin
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MEHDIZADE, KHADIJA
FACILITY NUMBER: 343626109
VISIT DATE: 09/16/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Applicant was encouraged to maintain supervision at all times. Applicant understands that if an unusual incident occurs, licensing is to be notified via phone call, e-mail or fax within 24 hours and the Unusual Incident Report LIC 624 shall be submitted within 7 days to remain in compliance.

LPA discussed Type A/B citations, open door policy, 100% supervision in unfenced areas and near bodies of water, fire drills, children’s personal rights, and smoking prohibition with the applicant. A current roster of children enrolled must be available and maintained for a period of three years, even after children are no longer in care. LPA reviewed ratio and capacity. Licensee understands that children that live in the home under the age of 10 years old count towards total capacity.

LPA explained to applicant that if they relocate and wants to continue to provide care, they must submit a change of location application and have the new home inspected. Applicant understands that if they want to make any off-limit area an on-limits area, licensing must be notified and LPA must do an inspection before children are allowed in the area. Applicant understand that licenses are not transferable, and once licensed, licensee must live in the home and be present for 80% of the operating hours.



Applicant was reminded that all adults 18 and over living in the home, persons who provide care and supervision to children, and staff who have contact with children, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5-days or, if the penalty is for a repeat violation, for a maximum of 30-days per person will be assessed if this regulation is violated.

The applicant provided proof of control of property. Because the applicant rents/leases the home, proof of landlord notification is required. The LPA observed the Property Owner/Landlord Notification form (LIC9151) that the applicant confirms was provided to the property owner/landlord. The applicant obtained a signed Property Owner/Landlord Consent form (LIC 9149).

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice) or (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: http://www.ada.gov/childqanda.htm.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Mandie Goodwin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO CC RO, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: MEHDIZADE, KHADIJA
FACILITY NUMBER: 343626109
VISIT DATE: 09/16/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPA reviewed with applicant the LIC 311D, Forms/Records to Keep In Your Family Child Care Homes, children’s forms/records, facility forms/records, and information to be posted. Entrance Checklist was provided to the applicant.

LPA discussed the safe sleep regulations with applicant and discussed the Child Care Licensing Safe Sleep webpage at: https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-andresources/safe-sleep, as an additional resource. LPA also informed applicant of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at: https://www.cpsc.gov/, and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

On this date, 8/26/24, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility addresses. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ.

Applicant was informed of the MyChildCarePlan.org site, a consumer education website that helps families obtain child care by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California

Exit interview conducted and report was reviewed with the applicants. Subscribe to CCLD important information - Child Care Centers and Family Child Care Homes: Community Care Licensing Division (CCLD) regularly sends information to licensed facilities, providers, and stakeholders by way of Provider Information Notices (PIN), Program Quarterly Update Newsletters and other important information communication platforms.

To receive important licensed related information to licensed facilities, visit the CCLD Important Information website at https://www.cdss.ca.gov/inforesources/community-carelicensing/subscribe and select the Child Care option to receive email communication.

As of 9/16/24 facility is approved for a Large Family Child Care Home license for a capacity of 12 children with no more than 4 infants, or up to 14 children with no more than 3 infants, 1 child in Transitional Kindergarten or above and 1 child at least age 6. Infants are children under the age of 2.
SUPERVISORS NAME: Seychelle De Luca
LICENSING EVALUATOR NAME: Mandie Goodwin
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3